VOLVULUS IN GIT

GASTRIC VOLVULUS SMALL BOWEL VOLVULUS (MIDGUT

MALROTATION) LARGE BOWEL VOLVULUS (CECAL VOLVULUS, SIGMOID VOLVULUS) LARGE AND SMALL BOWEL VOLVULUS

( ILEOSIGMOID KNOT)

DIFFERENT TYPES OF VOLVULUS

Gastric volvulus is a condition involving the stomach twisting upon itself

Classified as one of two typesorganoaxial or mesenteroaxial A combination of both types may occur in

an individual.

GASTRIC VOLVULUS

Twist occurs along a line connecting the cardia and the pylorus--the luminal (long) axis of the stomach.

Most common type. Usually associated with diaphragmatic

defects. Vascular compromise more common.

Organoaxial volvulus

Organoaxial volvulus the rotation of the stomach along its long axis

Twist occurs around a plane perpendicular to the luminal (long) axis of the stomach from lesser to greater curvature.

Chronic symptoms are more common. Diaphragmatic defects are less common.

Mesenteroaxial volvulus

Mesenteroaxial volvulus the stomach twisting along its short axis

◦ Abnormality of suspensory ligaments of stomach.

◦ Congenital defects of their diaphragm (Hiatal hernia).

◦ Weak Muscles (MND).◦ Tumors of stomach.

CAUSES OF GASTRIC VOLVULUS

Those with defects of the diaphragm commonly suffer with the common type (organoaxial volvulus), and it is the most serious form, needing urgent surgical intervention.

The mesenteroaxial type does not often lead to compromise of blood supply to the stomach speedily, and may run a chronic course.

◦Unless acute, patients are frequently asymptomatic.

◦When acute and obstructing Abdominal pain Attempts to vomit without results Inability to pass an NG tube Together, these three findings comprise

the Borchardt triad which is diagnostic of acute volvulus .

Clinical findings

In mesenteroaxial volvulus, distended stomach appears spherical on supine images.

Two air-fluid levels visible on upright film: in fundus and in antrum.

Upright image often demonstrates a beak where the esophagogastric junction is seen on normal images.

Radiography

peanut sign- in a case of chronic gastric volvulus.

The ultrasonographic features consist of a constricted segment of stomach, with 2 dilated segments located above and below the constricted part, akin to a peanut.

ULTRASONOGRAPHY

.

Gastric ischemia

◦ Gastric emphysema ◦ Twisting of stomach may tear spleen from its

normal attachments ◦ Perforation is rare

Complications

Torsion of the entire gut around superior mesenteric artery (SMA) due to a short mesenteric attachment of small intestine in malrotation.

Malrotation with a midgut volvulus

AGEo Usually neonate or young infanto Occasionally older child and adult

ASSOCIATED WITH (IN 20%) o Duodenal atresia o Duodenal diaphragmo Duodenal stenosis o Annular pancreas

o Degree of twisting is variable and determines symptomatology

o Severe volvulus (twist of 3 ½ turns) result in bowel necrosis Acute symptoms in newborn (medical

emergency)o Bile-stained vomiting Intermittent, Postprandial, Projectileo Abdominal distensiono Shock

Pathophysiology

Dilated, air-filled duodenal bulb and paucity of gas distally "Double bubble sign" = air-fluid levels in stomach & duodenum

o Isolated collection of gas-containing bowel loops distal to obstructed duodenum = gas-filled volvulus = closed-loop obstruction

From non resorption of intestinal gas secondary to obstruction of mesenteric veins

Plain film Findings

"Corkscrew" duodenum in malrotation with a midgut volvulus 

"Corkscrew" duodenum in malrotation with a midgut volvulus

CT findings Whirl-like pattern of small bowel loops and

adjacent mesenteric fat converging to the point of torsion (during volvulus)

SMV to the left of SMA (NO volvulus)

Chylous mesenteric cyst (from interference with lymphatic drainage)

Clockwise whirlpool sign = color Doppler depiction of mesenteric vessels moving clockwise with caudal movement of transducer

Distended proximal duodenum with arrowhead-type compression over spine

Superior mesenteric vein to the left of SMA

Thick-walled bowel loops below duodenum and to the right of spine associated with peritoneal fluid

US findings

"Barber pole sign" = spiraling of SMA

Tapering / abrupt termination of mesenteric vessels

Marked vasoconstriction and prolonged contrast transit time

Absent venous opacification / dilated tortuous superior mesenteric vein

Angio fIndings

Intestinal ischemia and necrosis in distribution of SMA (bloody diarrhea, ileus, abdominal distension)

DD:

Pyloric stenosis (same age group, no bilious vomiting)

Complications

Twisting of loop of intestine around its mesenteric attachment site may occur at various sites in the GI tract

Most commonly: sigmoid & cecum Rarely: stomach, small intestine, transverse

colon Results in partial or complete obstruction May also compromise bowel circulation

resulting in ischemia

Large bowel volvulus

Sigmoid volvulus most common form of GI tract volvulus

Accounts for up to 8% of all intestinal obstructions

Most common in elderly persons (often neurologically impaired)

Patients almost always have a history of chronic constipation

Sigmoid volvulus

Redundant sigmoid colon that has a narrow mesenteric attachment to posterior abdominal wall allows close approximation of 2 limbs of sigmoid colon à twisting of sigmoid colon around mesenteric axis

Other predisposing factors Chronic constipation High-roughage diet (may cause a long,

redundant sigmoid colon) Roundworm infestation Megacolon (often due to Chagas)

Pathophysiology

20-25% mortality rate Peak age > 50 years Torsion usually counterclockwise ranging

from 180 – 540 degrees Luminal obstruction generally @ 180

degrees Venous occlusion generally @ 360 degrees

à gangrene & perforation

DiagnosisAbdominal plain films usually diagnostic Inverted U-shaped appearance of distended sigmoid loop Largest and most dilated loops of bowel are

seen with volvulus Loss of haustra Coffee-bean sign à midline crease

corresponding to mesenteric root in a greatly distended sigmoid

Sigmoid volvulus – bowel loop points to RUQ

torsion of the caecum around its own mesentery which often results in obstruction

It accounts for 11% of all intestinal volvulus can result in bowel perforation and faecal

peritonitis

CECAL VOLVULUS

Clinical presentation Caecal volvulus presents with clinical

features of proximal large bowel obstruction. This is usually with colicky abdominal pain, vomiting and abdominal distension.

• Bowel loop points to LUQ • Dilated cecum comes to rest in left upper

quadrant

• Bird’s-beak or bird-of-prey sign à seen on barium enema as it encounters the volvulated loop

• CT scan useful in assessing mural wall ischemia

large, dilated loop of large bowel with an inverted U-shape with walls between two volvulated loops pointing from LLQ toward RUQ;same patient with decompressed sigmoid volvulus following insertion of rectal tube

Differential Diagnosis Large bowel obstruction due to other causes

à sigmoid colon CA Giant sigmoid diverticulum Pseudoobstruction

Complications Colonic ischemia Perforation Sepsis

Ba contrast enemacontrast-filled rectum illustrates the "bird's beak" sign (white arrow), corresponding to the luminal narrowing at the site of sigmoid obstruction. This is the characteristic presentation of a sigmoid volvulus

20 year old woman presented to the ED with 12 hours of abdominal pain, nausea. and vomiting low grade fever.

No past surgical history PMH: Polycystic ovarian disease

Case

Frontal scout

Dilated cecum

CT Axial with IV and rectal contrast

Cecum

CT Coronal reconstructions

ContrastIn Descending colonCecum

Barium Enema

Point of Obstruction

Ascending colon

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